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If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT (TMVI) WITH PROSTHETIC VALVE; PERCUTANEOUS APPROACH, INCLUDING TRANSSEPTAL PUNCTURE, WHEN PERFORMED

Service Code
0483T (CPT) TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT (TMVI) WITH PROSTHETIC VALVE; PERCUTANEOUS APPROACH, INCLUDING TRANSSEPTAL PUNCTURE, WHEN PERFORMED
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Infectious disease (Neisseria gonorrhoeae), sensitivity, ciprofloxacin resistance (gyrA S91F point mutation), oral, rectal, or vaginal swab, algorithm reported as probability of fluoroquinolone resistance

Service Code
0483U (CPT) Infectious disease (Neisseria gonorrhoeae), sensitivity, ciprofloxacin resistance (gyrA S91F point mutation), oral, rectal, or vaginal swab, algorithm reported as probability of fluoroquinolone resistance
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT (TMVI) WITH PROSTHETIC VALVE; TRANSTHORACIC EXPOSURE (EG, THORACOTOMY, TRANSAPICAL)

Service Code
0484T (CPT) TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT (TMVI) WITH PROSTHETIC VALVE; TRANSTHORACIC EXPOSURE (EG, THORACOTOMY, TRANSAPICAL)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Infectious disease (Mycoplasma genitalium), macrolide sensitivity (23S rRNA point mutation), oral, rectal, or vaginal swab, algorithm reported as probability of macrolide resistance

Service Code
0484U (CPT) Infectious disease (Mycoplasma genitalium), macrolide sensitivity (23S rRNA point mutation), oral, rectal, or vaginal swab, algorithm reported as probability of macrolide resistance
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Oncology (solid tumor), cell-free DNA and RNA by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and tumor-derived single-nucleotide variants, small insertions/deletions, copy number alterations, fusions, microsatellite instability, and tumor mutational burden

Service Code
0485U (CPT) Oncology (solid tumor), cell-free DNA and RNA by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and tumor-derived single-nucleotide variants, small insertions/deletions, copy number alterations, fusions, microsatellite instability, and tumor mutational burden
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (pan-solid tumor), next-generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor DNA, algorithm reported as quantitative measurement of methylation as a correlate of tumor fraction

Service Code
0486U (CPT) Oncology (pan-solid tumor), next-generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor DNA, algorithm reported as quantitative measurement of methylation as a correlate of tumor fraction
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (solid tumor), cell-free circulating DNA, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy-corrected gene copy number amplifications and losses, gene rearrangements, and microsatellite instability

Service Code
0487U (CPT) Oncology (solid tumor), cell-free circulating DNA, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy-corrected gene copy number amplifications and losses, gene rearrangements, and microsatellite instability
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected

Service Code
0488U (CPT) Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants, and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia)

Service Code
0489U (CPT) Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants, and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular-weight melanoma-associated antigen, CD34 and CD45 protein biomarkers, peripheral blood

Service Code
0490U (CPT) Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular-weight melanoma-associated antigen, CD34 and CD45 protein biomarkers, peripheral blood
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen r

Service Code
0491U (CPT) Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of estrogen r
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD-L1 prot

Service Code
0492U (CPT) Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytokeratins 8, 18, and 19, CD45 protein biomarkers, and quantification of PD-L1 prot
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA

Service Code
0493U (CPT) Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative

Service Code
0494U (CPT) Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer

Service Code
0495U (CPT) Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real-time RT-PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported positive or negative for colorectal cancer or advanced adenoma risk

Service Code
0496U (CPT) Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real-time RT-PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported positive or negative for colorectal cancer or advanced adenoma risk
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (prostate), mRNA gene-expression profiling by real-time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a risk score for prostate cancer

Service Code
0497U (CPT) Oncology (prostate), mRNA gene-expression profiling by real-time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a risk score for prostate cancer
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin-embedded (FFPE) tissue, report of variants and methylation pattern with interpretation

Service Code
0498U (CPT) Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin-embedded (FFPE) tissue, report of variants and methylation pattern with interpretation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, and TP53), mutation detection

Service Code
0499U (CPT) Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, and TP53), mutation detection
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

Oncology (colorectal), blood, quantitative measurement of cell-free DNA (cfDNA)

Service Code
0501U (CPT) Oncology (colorectal), blood, quantitative measurement of cell-free DNA (cfDNA)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore